Delta Dental of Michigan
Dental Benefit Highlights for
Michigan Technological University
High Plan
Delta Dental PPOSM (Point-of-Service)
Coverage Effective January 1, 2013
Delta Dental
PPO Dentist
Delta Dental
Premier®
Dentist
Plan Pays
Nonparticipating
Dentist
Plan Pays*
Plan Pays
Diagnostic & Preventive
Diagnostic and Preventive Services –
includes exams, cleanings, fluoride, and
100%
100%
100%
space maintainers
Emergency Palliative Treatment – to
100%
100%
100%
temporarily relieve pain
100%
100%
100%
Brush Biopsy – to detect oral cancer
Sealants – to prevent decay of permanent
100%
100%
100%
teeth
Radiographs – X-rays
100%
100%
100%
Basic Services
Periodontal Maintenance – cleanings by a
80%
80%
80%
specialist
Non-Surgical Periodontic Services – non80%
80%
80%
surgical services to treat gum disease
80%
80%
80%
Endodontic Services – root canals
80%
80%
80%
Repairs – to bridges and dentures
Oral Surgery Services – extractions and
80%
80%
80%
dental surgery
Minor Restorative Services – fillings and
80%
80%
80%
crown repair
Major Services
Surgical Periodontic Services – surgical
50%
50%
50%
services to treat gum disease
Major Restorative Services – crowns
50%
50%
50%
Prosthodontic Services – includes bridges,
50%
50%
50%
implants, and dentures
Relines – to bridges and dentures
50%
50%
50%
Inlays & Veneers
50%
50%
50%
Orthodontic Services
Orthodontic Services – includes braces
50%
50%
50%
Orthodontic Age Limit –
To age 20
To age 20
To age 20
* When you receive services from a Nonparticipating Dentist, the percentages in this column
indicate the portion of Delta Dental's Nonparticipating Dentist Fee that will be paid for those
services. This Nonparticipating Dentist Fee may be less than what your dentist charges, which
means that you will be responsible for the difference.
Maximum Payment – $1,500 per person total per calendar year on Diagnostic & Preventive, Basic
Services, and Major Services. $1,500 per person total per lifetime on Orthodontics.
Deductible – None.
Note - This document is intended as a supplement to your Certificate and Summary of Benefits.
Please refer to your certificate and summary for policy exclusions and limitations.
10/29/2012
Welcome to Michigan’s largest dental
benefits family!
As a member of Delta Dental of Michigan,
you have access to the nation's largest
dental networks: Delta Dental PPO and
Delta Dental Premier.
 Nationwide, 3 out of 4 dentists
participate
 Great access to care as well as reduced
fees through our agreements with
dentists
 You cannot be balance billed - giving
you added savings
 Network dentists will complete and file
your claim - no paperwork for you
 You only have to pay your copayments
and/or deductibles when you receive
dental services from a PPO or Premier
Dentist
 You don't have to wait for your claim to
be paid to be reimbursed!
While you can visit nonparticipating
dentists, you can be billed the full amount
immediately and then wait to be
reimbursed.
Quality Dental Program
Delta Dental provides quick and accurate
claims processing. We pay more than 90
percent of claims in 10 days or less. Delta
Dental also offers world-class customer
service from our award winning call center.
Online Access
Our online Consumer Toolkit lets you
access your dental plan securely over the
Internet. You can find a dentist, check
benefits, select paperless EOBs, review
claims and amounts used toward
maximums, print ID cards, and more at
your convenience.
A Healthy Smile
Keep your smile healthy with dental
benefits from Delta Dental. Your smile is a
good indicator of your health. Did you
know that your dentist can detect up to 120
different diseases, including diabetes and
heart disease? Early detection is one of the
best ways to prevent further complications.
Questions?
If you have questions, call our Customer
Service team at (800) 524-0149 or look
online at www.deltadentalmi.com.